Cracking the crock: how to deal with factitious eye disease.
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Diagnosis, Differential↗
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Factitial leg ulcers associated with an unusual sleep disorder.
A 19-year-old woman presented with a 14-month history of multiple, factitially induced, full-thickness leg ulcers. Nocturnal polysomnography with video monitoring revealed a short sleep latency and frequent sleep stage changes. Rapid eye movement sleep was absent. All stages of non-rapid eye movement sleep were associated with leg rubbing. After treatment that included avoidance of daytime naps and administration of chlorpromazine at bedtime, affect, daytime behavior, nocturnal sleep, and the ulcers improved markedly. To our knowledge, there are no reports of factitial dermatosis associated with disordered sleep. Our findings suggest that abnormal sleep may play a role in initiating or perpetuating factitial dermatoses. This case illustrates that polysomnography and video monitoring may be indicated in the evaluation of patients with factitial dermatoses.
Adult↗
Factitious triplegia: case report.
A 37-year-old woman was admitted for rehabilitation of triplegia with diagnoses of conversion disorder and possible multiple sclerosis. Attempts to manage the patient with techniques often effective with conversion disorders were unsuccessful, and the patient was discharged to a nursing home. After the development of further symptoms and a second extensive medical work-up, the factitious nature of her symptoms became evident. Awareness of the characteristics of factitious disorders, early background investigation, and psychiatric consultation can facilitate the appropriate management and referral of these patients, and spare rehabilitation providers the frustrations and possible medicolegal complications of patients with this disorder.
Adult↗
Clinical aspects of mast cell disorders in man and consideration of factitious urticaria.
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Age Factors↗
Recognizing factitious hypoglycemia in the family practice setting.
BACKGROUND: Factitious hypoglycemia is a deliberate attempt to induce a low serum glucose level using either insulin or oral hypoglycemic agents. Sulfonylurea-induced hypoglycemia is more common than incidents of insulin abuse, and hypoglycemia caused by these oral agents is biochemically indistinguishable from insulinoma. METHODS: We describe a case of factitious hypoglycemia resulting from insulin abuse in an adult diabetic patient, review the essentials of glucose homeostasis, and describe diagnostic tests that allow a differential diagnosis. RESULTS AND CONCLUSION: Factitious hypoglycemia is associated with a higher incidence of suicide, depression, and personality disorders. Insulin-induced hypoglycemia can be detected by an insulin to C-peptide ratio that is greater than 1.0. In the absence of proof to the contrary, insulinoma should be considered the cause of hypoglycemia until another diagnosis is established. The generally poor prognosis for patients with factitious hypoglycemia underscores the importance of early recognition of factitious disorders.
Adult↗
Antidepressant treatment outcomes of psychogenic movement disorder.
BACKGROUND: Psychogenic movement disorder (PMD) is a subtype of conversion disorder. We describe the outcomes of a series of PMD patients following antidepressant treatment. METHOD: Twenty-three outpatients with chronic PMD, diagnosed using Fahn and Williams' criteria, underwent psychiatric assessment. The patients were referred for assessment and management from January 2003 to July 2004. Fifteen agreed to be treated with antidepressants. Patients received citalopram or paroxetine; those who did not respond after 4 weeks of taking an optimal dose were switched to venlafaxine. Concurrently, 3 had supportive psychotherapy, and 1 had family intervention. Assessments included the DSM-IV-based Mini-International Neuropsychiatric Interview and scales measuring depression, anxiety, and motor and global severity. RESULTS: Eighteen patients (78%) had at least 1 Axis I diagnosis in addition to the somatoform diagnosis, and 3 (13%) had somatization disorder. Five (22%) had previous psychiatric contact. Nine (39%) had previously been treated with antidepressants, but only 4 (17%) had adequate trials. No significant differences existed in patient characteristics between treated and untreated groups. Among treated patients, Montgomery-Asberg Depression Rating Scale scores improved from baseline (p < .01). Two treated subgroups were identified: 10 patients (67%) had primary conversion disorder, of whom 8 had marked motor and global improvements with 7 complete remissions, and 5 (33%) had primary hypochondriasis, somatization disorder, or probable factitious disorder/malingering, of whom none improved. All of the patients with primary conversion disorder had a current or previous depressive or anxiety disorder compared with 40% (N = 2) of the patients with additional somatoform diagnoses. DISCUSSION: Our preliminary findings suggest that chronic PMD with primary conversion symptoms and with recent or current depression or anxiety may respond to antidepressants. Further well-designed studies, now under way, are required to confirm these findings.
Adult↗
Psychosis in borderline personality disorder.
Do patients with borderline personality disorder (BPD) display psychotic symptoms as part of their syndrome? This question has important theoretical significance, since it bears on the question of whether BPD lies 'on the border' of psychotic functioning, or whether it is unrelated to psychotic disorders. A review of available evidence suggests that 'narrowly defined' psychotic symptoms, such as those included under the DSM-III definition of psychosis, are rare in BPD. Furthermore, when such symptoms have been reported in BPD, they may have been attributable to a concomitant, possibly independent, disorder suffered by the patient, such as substance abuse or major affective disorder. Broadly defined psychotic symptoms, such as depersonalization, are much more often reported in BPD, but many of these symptoms have also been reported frequently in patients with non-psychotic disorders and in normals. Finally, the prevalence of factitious psychotic symptoms in BPD has not been systematically investigated. Thus, the evidence for psychotic symptoms in BPD remains equivocal.
Adolescent↗
[Schizophrenia and factitious cheilitis: a case report].
Factitious Cheilitis is a rare skin disorder which has been seen in patients with emotional disturbances, particularly in cases with neurotic and personality disorders. However, there have been no reports of factitious cheilitis seen in cases of schizophrenia. This study reports on a case of schizophrenic disorder, where the patient was observed to develop factitious cheilitis whilst subject to unstable psychiatric conditions. The case reported here is of a 59 year-old female widow, who has experienced the delusion of being controlled, the delusion of being possessed. Been subject to auditory hallucination and vague somatic pain for eight years and had a very poor psychotropic drug compliance. Observation revealed frequent licking of the lips unrelated to drug-induced dyskinesia, but as a possibly linked response to hallucination whilst subject to an intense unstable emotional and painful state. Factitious cheilitis was proved with biopsy of the lips and pathological findings of acanthosis, hyperkeratosis and parakeratosis. After psychiatric and dermatologic care, her cheilitic condition improved. This study demonstrates that factitious cheilitis can be seen in a schizophrenic patient, specifically where hallucination and emotional instability coupled with long-term licking of the lips can result in factitious cheilitis. The relationship of skin disorder and psychiatric illness is discussed.
Cheilitis↗
[Factitious disease in surgery. The problem of the self-induced disorder of wound healing].
Self-inflicted disorders of wound healing (lasting for 18 to 84 months and requiring 85 surgical interventions) were diagnosed in ten patients (8 women and 2 men, aged 29 years) nine of whom had undergone various operations. Retrospectively the indications for the primary operation (appendectomy in four, mastectomy, cholecystectomy, adnexectomy, removal of a lipoma and incision of a perineal abscess in one each) had not been unequivocal. One woman was also anorexic, two had "psychogenic seizures", and three had marital or partner problems. One man who had a self-inflicted skin emphysema committed suicide two years later, and one woman died of septicaemia after a self-induced wound healing disorder. The wound healing disorders finally healed in seven patients. Psychotherapy was successful in two patients.
Adolescent↗
A case of factitious fever and 'epilepsy'.
We describe the case of a 23 year old male who presented with a history of intermittent pyrexia associated with apparent episodic loss of consciousness. During these events, thermometers placed in the rectum and axillae supported the elevated oral temperature readings. After numerous investigations including electroencephalography had excluded organic disease, the patient was observed applying a hot douche to his rectum prior to his temperature being recorded.
Adult↗
[Munchausen's syndrome: a diagnostic challenge].
The Munchausen's syndrome is a variant of chronic factitious illness with predominantly physical signs and symptoms under the conscious control of the patient without any obvious gain. The disorder has also been called hospital addiction, professional patient syndrome and in the field of dermatology, dermatitis artefacta. Munchausen's syndrome may mimic many different conditions, especially acute abdominal pain, hemorrhagic disorders, rheumatologic manifestations, factitious fever, and injury of skin. We describe a 28-year-old woman, who was admitted at a local teaching hospital and studied during three years with complaints of a bleeding ulcer on the left knee, severe enough to require blood transfusions. Many procedures and tests were performed without pathologic findings. Afterward, she was seen at our institution; during the study, the suspicion had arisen that the patient had manipulated her ulcer, after the diagnosis of factitious disease was communicated, she admitted. Munchausen's syndrome may have a broad spectrum of manifestations; early recognition can avoid unnecessary treatments and invasive diagnostic studies, with their inherent risk of complications.
Adult↗
Factitious psychosis: phenomenology, family history, and long-term outcome of nine patients.
Factitious psychological symptoms are defined in DSM-III as symptoms that are under the patient's voluntary control. Using specific criteria for the presence of voluntary control, the authors identified a cohort of 9 patients with factitious psychotic symptoms from among 219 patients consecutively admitted to a research ward for psychotic disorders. The phenomenology and family history of the patients suggested that they were a homogeneous group. All had similar DSM-III personality disorders, and most had a remarkably poor long-term outcome.
Adult↗
[Psychogenic disorders: concepts, terminology and classification].
The neurological interest on functional or psychogenic disorders (mental or physical disturbances with no organic basis, generally unleashed by stressful situations) has been receiving increasingly more interest over the last few years. In this article we review concepts, terms and classifications of these disorders, very different over time and among different authors. Psychogenic disorders are divided into: a) dissociation (with memory, consciousness and self-identity impairment), and b) disturbances with somatizations, divided into somatoform (unconscious), factitious (voluntary search for patient's role) and malingering (searching for material gain). Special emphasis is placed on conversion or hysteria, included in somatoform disorders. New findings in functional neuroimaging are analyzed. These new data suggest an important role of unconscious and involuntary inhibition in loss of volition (similar to hypnosis and different from malingering). Normal activity in certain brain areas (motor or sensory cortex) is blocked by other areas related to emotional integration (anterior cingular and orbitofrontal cortex). The neurologist's role is important to achieve an early diagnosis of psychogenic disturbances, particularly conversive ones. This means the use of fewer economic resources and better prognosis for the patient.
Dissociative Disorders↗
Munchausen syndrome by proxy: a study of psychopathology.
Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years. Approximately one-half of the mothers in this study had either smothered or poisoned their child as part of their fabrications. Lifetime psychiatric histories are reported for 47 of the mothers. Thirty-four had a history of a Factitious or Somatoform disorder, 26 a history of self harm, and 10 of alcohol or drug misuse. Nine mothers had a forensic history independent of convictions related to child abuse. Nineteen of these mothers were interviewed from 1-15 years after the original fabrications. The most notable psychopathology was the presence of a personality disorder in 17 of the mothers, which were predominantly Histrionic and Borderline types. Most subjects, however, met the criteria for more than one category of personality disorder.
Adolescent↗
Psychogenic intractable sneezing: case reports and a review of treatment options.
OBJECTIVE: To report 2 cases of the uncommonly seen diagnosis of psychogenic intractable sneezing, to review the clinical presentation, workup, and various previous treatment modalities, and to present a unique method of treatment. DATA SOURCES: The literature was reviewed using a MEDLINE search of the following keywords: psychogenic intractable sneezing, paroxysmal sneezing, factitious sneezing, respiratory disorders, conversion disorders, habit cough, and psychogenic cough. The search was restricted to articles published from 1966 onward, although older references were cross-referenced from more recent articles. RESULTS: Sneezing alone can be caused by foreign substances, odors, chemical irritants, allergies, and other less common factors. Psychogenic intractable sneezing, although not a particularly common disease, occurs mainly in adolescent girls for which a cause may not be found. Patients are usually refractory to various medications and have an otherwise unremarkable extensive workup. Treatments have included corticosteroids, antihistamines, hydroxyzine hydrochloride, and decongestants among other pharmacologic agents, as well as psychotherapy. Based on the presented case reports, a trial of isotonic sodium chloride solution with suggestion therapy was able to rid the patients of their intractable sneezing. CONCLUSIONS: Psychogenic intractable sneezing is a real disease. Although other diseases may be considered, the workup may merely include an extensive history and physical examination. Many treatments have been tried with varying success, including those that incorporate psychotherapy. A variation of suggestiontherapy is offered as a unique treatment modality.
Child↗
Factitious sexual harassment.
Among those claims that trivialize true sexual harassment is a type that the author has come to recognize as factitious (i.e., prompted by the lure of victim status). Women who file factitious sexual harassment cases usually voice their allegations in a very convincing manner and, in the presence of contradictory findings, present a diagnostic challenge. Forensic clinicians must be able to recognize factitious sexual harassment in order to bring objectivity to these complex cases.
Adult↗
Factitious illness following toenail surgery.
A 14-year-old white female is treated for a common ingrown toenail with a permanent ablative procedure. The patient feigns factitious illness in the form of a postoperative infection to prolong medical care. No past history of neurotic disorder is related. Finally, after five hospitalizations, factitious illness is identified.
Adolescent↗